Allergy to human insulins and analogues: Follow-up of patient submitted to a tolerance induction protocol

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SAT 786-805-Diabetes & Obesity Therapeutics
Bench to Bedside
Saturday, June 15, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SAT-793
Marcelo Fernando Ronsoni*1, Bruno da Silveira Colombo1, Mariana Costa Silva1, Camila Colin2, Maria Heloisa Busi da Silva Canalli1, Cristina da Silva Schreiber de Oliveira1, Maria Anita Costa Espindola Bez Betti1, Rosa Maria Mazzuco1, Marisa Helena Cesar Coral1 and Alexandre Hohl1
1Federal University of Santa Catarina, 2Private Practice
Introduction: There are several types of allergic hypersensitivity to drugs. Anaphylactic shock is the worse representation of immediate-type hypersensitivity. IgE mediated allergy (immediate-type) to human insulin and analogues is rare, but needs tolerance induction protocols.

Case Report: Female, 54 y.o., dyslipidemic, become diabetic after partial pancreatectomy (pancreatitis) and was unresponsive to oral therapy (oral antidiabetics and subcutaneous [SC]). Previous history of skin reaction to the tetanus vaccine and angioedema after bee sting. After initiation of NPH and Regular Insulin (RI) showed rash in the first applications. After 4 weeks, presented anaphylactic shock. It was first attempted reintroduction of NPH insulin associated with prednisone and then, analogues Lispro and Glargine, but she experienced angioedema, and dyspnea. On examination, BMI 27.9 kg/m2, SBP 160 mmHg. Labs: fasting glucose 143 mg/dL, HbA1c 9.6%, C-peptide 3.27 ng/mL (normal range [NR] 1.1-5.0), total cholesterol 302 mg/dL (NR <200), HDL 57 mg/dL (VR > 50), LDL 208 mg/dL (VR <100), triglycerides 412 mg/dL (VR <150). Human (NPH and RI) and analogue insulins (Levemir, Lispro and Glargine) were evaluated by allergy prick tests (PT) and intradermal (ID) at doses of 0.1 to 100 IU/mL. Strongly positive tests to all insulins. The patient accomplished tolerance induction to RI  in the intensive care unit (best profile skin test). Twelve RI injections at intervals of 20 min (6 ID 0.02 mL [concentration 0.5], and after 6 SC). We observed papules in the injection area that progressively decreased with each new dose. After that, doubled dose every 4h were made until glycemic control. Prescribed RI 3x/day (10 IU) and Metformin + ddp-4 inhibitor. At 60 days she restarted with pain and induration at the sites of application, skin rash and angioedema. After that, it was associated fexofenadine 180 mg and hydroxyzine 25mg and maintained the IR. She kept only local complaints. Six months after, A1c 6.4% and BMI 39.3 kg/m2.

Discussion: We report the follow-up of a patient with insulin allergy submitted to a tolerance induction protocol to human insulin. Although rare and with a few data in the literature, we adapted a protocol for our hospital. Despite local complaints, the improvement of glycemic profile was obtained without systemic repercussions. We emphasize the need to develop specific protocols for patients with intolerance to insulin.

Nothing to Disclose: MFR, BDSC, MCS, CC, MHBDSC, CDSSDO, MACEBB, RMM, MHCC, AH

*Please take note of The Endocrine Society's News Embargo Policy at http://www.endo-society.org/endo2013/media.cfm